REPUBLIC OF THE PHILIPPINES)

Tanza, Cavite )S.S

AFFIDAVIT OF CHANGE COLOR

Mark Anthony Velasco of legal age, Filipino, (single/married/widow) and a resident of

I, ___________________,
_______________________________, after having been duly sworn to in accordance with law, depose
and state THAT:

1. I am the registered owner of a motor vehicle which is particularly described as follows:

Make & Type: ______________

Motor Number : ______________
Chassis Number: ____________
Plate Number: ______________________________
MV File No. : ________________
Year Model: _________________
Color: _____________________

Matte Black
2. The original color of the said motor vehicle was "_____________";

White- Blackto
3. When the paint of the above-described motor vehicle had faded, I had its color repainted
"_________" such that the color of the said motor vehicle was
Mattechanged
Black from
White-"_________"
Black to
"________";

4. Said change of color is not intended for any illegal or unlawful purpose but solely due to the foregoing
reasons;

5. I am executing this Affidavit to attest to the truth of the foregoing and in support of the application for
the change of color of the above-described motor vehicle on its Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in

Tanza, Cavite Philippines.

____________________
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity by
way of __________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.